WJ P
World Journal of
Psychiatry
World J Psychiatr 2014 December 22; 4(4): 120-132
ISSN 2220-3206 (online)
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Submit a Manuscript: http://www.wjgnet.com/esps/
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DOI: 10.5498/wjp.v4.i4.120
REVIEW
Antecedents and sex/gender differences in youth suicidal
behavior
Anne E Rhodes, Michael H Boyle, Jeffrey A Bridge, Mark Sinyor, Paul S Links, Lil Tonmyr, Robin Skinner,
Jennifer M Bethell, Corine Carlisle, Sarah Goodday, Travis Salway Hottes, Amanda Newton, Kathryn Bennett,
Purnima Sundar, Amy H Cheung, Peter Szatmari
Anne E Rhodes, Institute for Clinical Evaluative Sciences,
Toronto M4N 3M5, Ontario, Canada
Anne E Rhodes, Mark Sinyor, Corine Carlisle, Amy H
Cheung, Peter Szatmari, Department of Psychiatry, University
of Toronto, Toronto M5T 1R8, Ontario, Canada
Anne E Rhodes, Jennifer M Bethell, Suicide Studies Unit, St.
Michael’s Hospital, Toronto M5B 1W8, Ontario, Canada
Anne E Rhodes, Sarah Goodday, Travis Salway Hottes,
Dalla Lana School of Public Health, University of Toronto,
Toronto M5T 3M7, Ontario, Canada
Michael H Boyle, Kathryn Bennett, Department of Psychiatry
and Behavioural Neurosciences, McMaster University, Hamilton
L8N 3K7, Ontario, Canada
Michael H Boyle, Kathryn Bennett, The Offord Centre for
Child Studies, Hamilton L8S 4K1, Ontario, Canada
Jeffrey A Bridge, The Research Institute at Nationwide Children’s
Hospital, Columbus, OH 43205, United States
Jeffrey A Bridge, The Ohio State University College of
Medicine, Columbus, OH 43210, United States
Mark Sinyor, Amy H Cheung, Sunnybrook Health Sciences
Centre, Toronto M4N 3M5, Ontario, Canada
Paul S Links, Department of Psychiatry, University of Western
Ontario, London N6A 5W9, Ontario, Canada
Lil Tonmyr, Robin Skinner, The Injury and Child Maltreatment
Section, Public Health Agency of Canada, Ottawa K1A 0K9,
Ontario, Canada
Corine Carlisle, Peter Szatmari, The Centre for Addiction and
Mental Health, Toronto M6J 1H4, Ontario, Canada
Amanda Newton, Department of Pediatrics, University of
Alberta, Edmonton, Alberta T6G 1C9, Canada
Kathryn Bennett, The Department of Clinical Epidemiology
and Biostatistics, McMaster University, Hamilton L8S 4K1,
Ontario, Canada
Purnima Sundar, The Ontario Centre of Excellence for Child
and Youth Mental Health, Ottawa K1G 0Z1, Ontario, Canada
Peter Szatmari, The Hospital for Sick Children, Toronto M5G
1X8, Ontario, Canada
Author contributions: Rhodes AE, Boyle MH and Bridge JA
contributed to the conception and design; Rhodes AE, Bridge
JA and Szatmari P contributed to the acquisition of data, and
the analysis and interpretation of data (all authors); Rhodes AE
contributed to the drafting of the article, and its critical revision
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for important intellectual content; all authors contributed to the
analysis, critical revision for important intellectual content and
interpretation of data gave their final approval of the version to
be published.
Supported by The Canadian Institutes of Health Research, No.
319379
Conflict-of-interest: The authors have no conflict of interests.
Open-Access: This article is an open-access article which
selected by an in-house editor and fully peer-reviewed by
external reviewers. It distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Correspondence to: Anne E Rhodes, PhD, Suicide Studies
Unit, St. Michael’s Hospital, 30 Bond Street, Toronto M5B 1W8,
Ontario, Canada. [email protected]
Telephone: +1-416-8646099
Fax: +1-416-8645996
Received: September 27, 2014
Peer-review started: September 28, 2014
First decision: October 21, 2014
Revised: November 13, 2014
Accepted: November 27, 2014
Article in press: December 1, 2014
Published online: December 22, 2014
Abstract
Suicide is the second leading cause of death in youth
globally; however, there is uncertainty about how best
to intervene. Suicide rates are typically higher in males
than females, while the converse is true for suicide
attempts. We review this “gender paradox” in youth,
and in particular, the age-dependency of these sex/
gender differences and the developmental mechanisms
that may explain them. Epidemiologic, genetic,
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Rhodes AE et al . Sex/gender and youth suicide
in youth[8]-a problem that may be resolved, in part, by
addressing sex/gender differences in suicidal behaviours.
neurodevelopmental and psychopathological research
have identified suicidal behaviour risks arising from
genetic vulnerabilities and sex/gender differences in
early adverse environments, neurodevelopment, mental
disorder and their complex interconnections. Further,
evolving sex-/gender-defined social expectations
and norms have been thought to influence suicide
risk. In particular, how youth perceive and cope with
threats and losses (including conforming to others’
or one’s own expectations of sex/gender identity)
and adapt to pain (through substance use and helpseeking behaviours). Taken together, considering
brain plasticity over the lifespan, these proposed
antecedents to youth suicide highlight the importance
of interventions that alter early environment(s) (e.g. ,
childhood maltreatment) and/or one’s ability to adapt
to them. Further, such interventions may have more
enduring protective effects, for the individual and for
future generations, if implemented in youth.
Gender paradox
Herein, the “gender paradox”-higher suicide attempt
rates in females but higher suicide rates in males-merits
attention[9]. In particular, this paradox is age dependent.
For suicide attempt rates, the sex/gender difference (F
> M) increases with age peaking in mid adolescence[10-13],
whereas for suicide rates, the sex/gender difference (M >
F) steadily climbs until early adulthood[1]. Although suicide
attempt data are self-reported, hospital presentation data
reveal the same pattern[14-17] and suicide misclassification
seems an unlikely explanation[18]. Why do these changes
occur and could this knowledge help us reduce suicide
risk in boys and girls?
Purpose of this review
We build on developmental perspectives of youth
suicidal behaviours[2,19] to advance our understanding of
the mechanisms underlying the gender paradox, which
may help focus approaches to youth suicide prevention.
In the following sections, we examine the continuum of
suicidal behaviours in boys and girls, synthesizing findings
from epidemiologic, genetic, neurodevelopmental and
psychopathology research to propose key mechanisms.
We then highlight how these mechanisms operate within
the sex/gender developmental contexts in which youth
live, which if modified, may reduce their suicide risk.
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Key words: Suicide; Attempted suicide; Sex; Gender;
Child; Adolescent; Review
Core tip: Previous research has demonstrated clear and
consistent sex-/gender-specific patterns in the continuum
of suicidal behaviour. Here, we review epidemiologic,
genetic, neurodevelopmental and psychopathological
research to identify and discuss explanations for these
findings. We propose antecedents to youth suicide
and highlight the importance of early intervention.
Understanding the mechanisms underlying sex/gender
differences in youth suicidal behaviour could help
identify strategies to reduce suicide risk across the
lifespan.
Terminology
“Boys” and “girls” refer to youth ages 10 to 24 years[20].
“Sex/gender” is used rather than “sex” or “gender” to
signify the complex interplay of social and biological
determinants[21]. Most findings are limited by dichotomous
measures of sex/gender[22], and to Western cultures. We
defined suicidal ideation, attempts and suicide according to
standard nomenclature[23]. Hereafter, hospital presentation
data on self-inflicted injuries and poisonings are referred
to as “hospital presentations” or when admitted, “hospital
admissions”. For both, unless otherwise noted, suicidal
intent was unspecified.
Rhodes AE, Boyle MH, Bridge JA, Sinyor M, Links PS, Tonmyr
L, Skinner R, Bethell JM, Carlisle C, Goodday S, Hottes TS,
Newton A, Bennett K, Sundar P, Cheung AH, Szatmari P. Antecedents and sex/gender differences in youth suicidal behavior.
World J Psychiatr 2014; 4(4): 120-132 Available from: URL:
http://www.wjgnet.com/2220-3206/full/v4/i4/120.htm DOI:
http://dx.doi.org/10.5498/wjp.v4.i4.120
SEX/GENDER DIFFERENCES IN THE
CONTINUUM OF SUICIDAL BEHAVIOUR
INTRODUCTION
In this section, we review the epidemiologic evidence
for a proposed continuum from suicidal ideation to
behaviours, with those attempting and dying by suicide
experiencing a greater burden of risk[24-26].
Problem
Suicide is the second leading cause of death among
young people globally with substantial social and
economic costs[1]. While youth suicide rates vary widely
across and within countries[2,3], in developed countries,
with good-quality vital registration data[1], rates are at least
2 to 3 times higher in boys than girls[4,5]. Suicide rates have
declined in boys since the 1990s, but there is concern that
in some countries, rates have increased for girls[6] and the
downward trend in boys, is now reversing[7]. However,
it is unclear how best to intervene to reduce suicide risk
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Suicide attempts
Several factors complicate our understanding of suicide
attempts in boys and girls as they age. First, knowledge
from community-based samples (i.e., school or household
surveys) may be slanted to girls because girls have a higher
past year[27-30] and lifetime prevalence[25,29,31,32] of suicidal
ideation and attempts than boys between the ages of 12
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Rhodes AE et al . Sex/gender and youth suicide
to 24. Second, depending on the study design, younger
youth may not be well-represented given the prevalence
of suicide attempts is highest in mid adolescence, and
the lifetime recall of suicide attempts is inconsistent,
particularly at early ages[33]. Third, community-based
surveys tend to represent more common, but less lethal
behaviours. For example, although 8.0% of United States
students (grades 9 to 12) reported a past year suicide
attempt, the proportion reporting their attempt was
treated by a doctor or nurse was only 2.7% (higher in girls
than boys, 3.6% vs 1.8%)[28]. The sex/gender difference
in youth suicide attempts (F > M) only diminishes
among hospital presentations in medically serious suicide
attempts (largely self-poisonings)[34] and reverses (M >
F) with increased lethality of methods (e.g., hanging and
firearms)[35,36].
With these caveats, we review prospective communitybased studies where the temporal ordering between
potential predictors of suicide attempts is less ambiguous,
to illustrate cumulative risks and potential causal chains
in boys and girls as they age. Suicidal ideation, tied to
depression[10,37], is a predictor of a later attempt[24,37,38]; but
more for girls than boys[10,26]. Further, when depression
and suicide attempts were compared by age in girls,
suicide attempts declined in older girls (narrowing the
F > M difference) but depression did not[10], raising the
question what accounted for this decline and its relevance
to suicide prevention?
Other longitudinal studies have shown that suicide
attempt risk is predicted by early adverse environments
and early psychiatric morbidity. However, it remains
unclear whether boys’ and girls’ pathways differed. For
example, in a New Zealand birth cohort study[39], after
adjusting for predictors collected prior to ages 15 to 16:
lower socio-economic status (SES) at birth, parental
alcohol problems, childhood sexual abuse and poor
parental attachment along with predictors collected
at ages 15 to 16: neuroticism and novelty seeking, the
initially higher risk of a suicide attempt in girls compared
to boys between the ages of 15 to 21 was attenuated (RR
= 1.73 to 1.17). While tentative, this attenuation of risk
hints that the F > M difference in suicide attempts is
mediated by one or more of these predictors. Also, this
study noted that the predictors’ effects were later largely
mediated by mental disorders and stressful life events,
except for low SES at birth, neuroticism and novelty
seeking. That is, the predictive power of early adverse
environments on suicide attempts was reduced as youth
aged, mediated, in part, by psychiatric morbidity and
stressful life events.
Further research indicated that for youth who
attempted suicide, psychiatric morbidity was evident earlier
than age 15, coinciding with environmental effects. In a
study of kindergarten students[40] teacher-rated trajectories
of anxiousness and/or disruptiveness (between the ages
of 6 to 12) predicted lifetime suicide attempts by age 15
to 24. Sex/gender (along with childhood sexual abuse
before age 18 and a family history of suicide attempts)
remained predictive. Potential sex/gender differences in
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these pathways and possible mediators of sex/gender
differences were difficult to interpret, though, as the study
attrition in boys was 50% and the temporal sequence of
events, uncertain. Notably, boys were overrepresented
among students with disruptiveness or both trajectories
by age 12; however, girls with both trajectories were most
likely to report a suicide attempt at ages 15 to 24[40].
Suicide
We now consider how boys and girls differ along the
continuum from suicide attempts to suicide as they
age. Given suicide rates are higher in boys and increase
with age, samples may be slanted more towards older
males. Because youth suicide is rare[1], information from
studies of community-based samples often comes from
retrospective “psychological autopsies”. Such studies
typically have small samples and rely on informants’
recall, usually family members. Informants may have
difficulties reporting on more personal or distant aspects
of the decedent’s life (e.g., childhood sexual abuse
or a suicide attempt). Differential reporting may be
overcome by interviewing similar informants for both
controls and decedents but problems of statistical power
preclude testing some associations. Suicide attempts and
suicides share many predictors, including early adverse
environments [2]; however, the temporal sequencing
between predictors, and by sex/gender, has been harder
to discern for suicide.
A prior suicide attempt is one of the strongest known
predictors of youth suicide[2], but potential sex/gender
differences overall, and by age of onset are unclear.
Prospective hospital presentation data confirm these
youth have a higher suicide risk (about 10 times) than
their peers[41]. Suicide risk is strongest in the year after the
presentation, but remains elevated in subsequent years[42].
However, these risks likely differ by age and method.
Unlike older samples where a hospital admission with a
more lethal method (vs self-poisoning) predicts suicide
in men and women[43], in youth aged 10 to 18, a hospital
presentation for self-cutting (vs self-poisoning) is more
predictive of suicide[42], a method of lower lethality[44,45],
associated with repetition[42]. Repeat (vs single) hospital
presentations are more strongly associated with suicide,
particularly in girls[46]. However, self-poisonings, usually
medication overdoses in Western cultures[14], are the most
common hospital presentation among youth[3] and sex/
gender differences in lethality are not evident here[44].
In a case-control study of suicidal behaviour under
age 25, youth who died by suicide and those who
made a medically serious suicide attempt shared most
predictors, including a prior suicide attempt[35], and only
two predictors discriminated these youth: sex/gender and
a current mood disorder. Compared to youth who made
a medically serious suicide attempt, youth who died by
suicide were more likely to be male (81.7% vs 45.6%) but
were less likely to have a current mood disorder (30.0% vs
71.2%). Differential reporting of mood symptoms by the
informants seemed less likely given the severity of the
events being compared. Supplementary analyses revealed
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Rhodes AE et al . Sex/gender and youth suicide
that the higher proportion of boys among youth who
died by suicide was explained by their lower prevalence
of a current mood disorder and greater prevalence of a
highly lethal method. The possibility that younger age,
early adverse environments (e.g., childhood sexual abuse)
and dimensional measures of psychiatric morbidity
(e.g., impulsive aggression, defined below) might predict
more lethal methods was unexplored. Compared to
peers, childhood sexual abuse was associated with a
medically serious suicide attempt (OR = 7.4) as well as
a current substance use disorder (OR = 3.1). However,
such comparisons with peers were not reported for
youth who died by suicide. While not explicitly tested, a
lifetime history of antisocial behaviour (26.7% vs 36.8%)
or of care for mental health problems (50.0% vs 68.8%)
appeared less prevalent in youth who died by suicide than
among those with a medically serious suicide attempt.
In keeping with the findings on youth suicide
attempts[40], a Finnish birth cohort study[47] found parent and
teacher ratings of anxiety and/or conduct disorder at age 8
predicted later hospital admissions and/or suicides among
boys aged 8 to 24. Yet, measures of psychopathology at age
8 were not predictive in girls, implying different pathways
and timing of effects in boys and girls.
Collectively, these studies demonstrate important
differences between boys and girls in the prevalence and
lethality of suicidal behaviours; however, the reasons
for these differences and the timing of their effects,
critical for prevention efforts, have seldom been studied.
Nevertheless, community-based studies support a model
of youth suicide attempts whereby their onset is predicted
by early adverse environments in concert with differing,
early psychiatric morbidity (i.e., neuroticism, anxiousness
vs novelty seeking, disruptiveness). Past suicidal ideation
(and concurrent depression) may be more predictive of
suicide attempts in girls than boys, and among girls, most
predictive in mid adolescent vs older girls. With respect to
suicide, the effect of a prior suicide attempt may differ in
boys and girls, dependent on the method’s lethality and
care for mental health problems. Community-based and
hospital presentation studies indicate that the proportion
of boys (vs girls) with a suicide attempt increases with
the attempts’ lethality and at this end of the continuum,
factors other than a current mood disorder seem
significant. However, what these factors are (e.g., early
adverse environments and/or other types of psychiatric
morbidity) and how they may differ in boys and girls
with age, influencing mental health care is uncertain. In
the following sections, we turn to other lines of evidence
to improve our understanding of the inter-relationships
between early environments, psychiatric morbidity, helpseeking and the gender paradox.
controlling for familial transmission of mental disorders
(unlike suicidal ideation) and this transmission does not
seem to be explained by imitation effects[48]. Further,
there is some evidence that the elevated risk of suicide
among offspring exposed to a parent’s suicide is highest
among youth who were under the age of 17 when
exposed. Impulsive aggression, (i.e., reacting with hostility
or aggression to frustration or provocation) [48], may
mediate the familial transmission, and stem from genetic
vulnerabilities and/or adverse early environments[49]. It
has been hypothesized that vulnerabilities to suicide arise
from gene/environment interactions occurring during
critical windows of brain development. Identifying sex/
gender developmental differences may help focus targets
for intervention[50,51].
More specifically, there is evidence that early adverse
life events, particularly childhood maltreatment (physical
or sexual abuse, neglect), have an enduring impact on the
brain both through genetic vulnerabilities (e.g., variation in
single nucleotide polymorphisms) and telomere erosion
making some individuals more vulnerable to brain changes
and through “epigenetics”[52-56]: changes in gene expression
mediated by altered chromatin without modifying the
DNA sequence[57]. While the genetic structure (genotype)
transmitted to offspring from their parents at conception
is unchanged, offspring gene expression may be
modified by environmental exposures. Several epigenetic
mechanisms have been proposed, which could in theory,
influence sex/gender differences in psychopathology,
(e.g., sex hormone induced differences and/or differential
exposures to environmental risk factors, including drugs
of abuse and child maltreatment)[54,58]. There is an ongoing
debate about parent-to-child transmission of epigenetic
effects[59].
Youth who die by suicide experience child maltreatment
more often than their peers and at an earlier age than
their peers-in one study the respective proportions were:
60.0% vs 18.0% by age 9 and 77.0% vs 34.0% by age 14[60].
Thus, it seems that for many youth who die by suicide,
their neurodevelopment was affected, and dependent on
their age, may have had an enduring impact, creating a
“diathesis”[61] affecting their ability to flourish cognitively,
emotionally and behaviourally in their environments[40,53].
We highlight childhood sexual abuse, as it has been found
to be associated with suicide attempt(s), independently
of other forms of child maltreatment in cross-sectional
studies among youth. Further, the magnitude of this
association is stronger in boys than girls[62,63]. Yet, this
sex/gender difference is not evident in adults[64] implying
the nature and timing of the abuse differs for boys
and girls. In fact, there is some evidence that for boys,
childhood sexual abuse typically occurs prior to puberty;
is more forceful and usually perpetrated by another male.
However, boys are less likely than girls to disclose the
abuse. The lack of this sex/gender difference in adults
may be explained, in part, by differential reporting and/or
selection biases, including mortality[62,64].
Given that brain plasticity lessens in adulthood,
interventions that alter environment(s) and/or an individual’s
SEX/GENDER DIFFERENCES IN GENETIC
VULNERABILITIES AND SUICIDAL
BEHAVIOUR
Suicidal behaviours aggregate within families after
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Rhodes AE et al . Sex/gender and youth suicide
accelerated grey matter loss has been found in youth who
transition to psychosis[69]. With maturation, the prefrontal
cortex becomes increasingly involved in modulating
responses to novel or rewarding events. Exogenous
behaviours (automatic responses to external stimuli – one
definition of impulsivity)[70]-tend to become balanced by
more endogenous, goal directed, planning behaviors[68,71].
Indeed, engagement in “risky” behaviours seems to peak
during adolescence but then decline[72,73], not unlike the
age-suicide attempt distribution evident in girls[10]. Given
sex-by-age interactions occur in cortical development,
including faster myelination in girls than boys[74], disruptions
in neurodevelopment, prior to or during this time may
solidify with maturation contributing to the onset of
different psychopathologies in boys and girls.
The way youth exert cortical control in response to
threats and rewards depends upon the subcortical brain.
Indeed, heightened behavioural inhibition has been
posited to place youth at greater risk for mood and anxiety
disorders[75]. It is noteworthy then, that the amygdala is
highly connected to both cortical and subcortical brain
regions and is one of the few regions known to contain
sex hormone receptors. Thus, dependent on early social
and biological environmental exposures, which may vary
by sex/gender, amygdala development seems critical in
how boys and girls appraise and respond emotionally
and behaviourally to their environments. The amygdala
is involved in face processing (social cues), fear learning
and extinction and can modulate HPA activity (the fight
or flight stress response). The rate of amygdala growth
is related to pubertal development in boys and girls[76,77].
Girls tend to have larger left amygdala volumes than boys
(aged 10 to 22 years)[78]. Further, a recent longitudinal
study found that increased amygdala growth from ages
12 to 16 years was associated with onset of depression in
girls (ages 12 to 18) but not boys[79]. Reduced amygdala
activity has been linked to callous-unemotional traits,
such as reduced responses to other’s fear, mediating
proactive (vs reactive) aggression in conduct disordered
youth[80]. The above neurodevelopmental findings have
some consistencies with knowledge about sex/gender
differences in youth mental disorders. In the following
section, we review sex/gender differences in the general
population of youth and then, among youth who die by
suicide.
adaptations to it, may have more enduring protective effects
(i.e., for those individuals and future generations) if first
implemented in youth. In the next section, we describe how
neurodevelopmental disruptions may give rise to different
types of psychopathology in boys and girls which may then,
contribute to the gender paradox.
SEX/GENDER DIFFERENCES IN
NEURODEVELOPMENTS AND
PSYCHOPATHOLOGY
Increasingly, psychopathology is viewed within a neur­
odevelopmental lens[58,65,66]. However, current nosology
systems [e.g., the Diagnostic and Statistical Manual (DSM)
for Mental Disorders and the International Classification
of Diseases] are based on categorical clusters of signs
and symptoms which lack neurobiological substrates.
Thus, mental disorders are defined and measured relying
heavily on how signs and symptoms are communicated
and considered abnormal within cultures. Lack of
knowledge, stigma and discrimination may prevent
disclosing symptoms. Suicidal behaviours are still illegal
in some countries[1]. It is only recently, (i.e., within DSM 5),
that suicidal behaviours have been identified separately
from mental disorders, (i.e., not presumed to be fully
explained by a mental disorder)[67]. Increasingly, research
is employing dimensional systems, including biological
measures, to better capture sub threshold conditions
and changes over time. Categorical systems have been
criticized for producing somewhat arbitrary boundaries,
possibly confusing temporal sequences and shared/
unique etiologies. Nonetheless, standard diagnostic
criteria across time and place provide useful “phenotypic”
infor mation which can be refined, iteratively, as
knowledge grows about etiological substrates “ranging
from environmental disruptions to genetically determined
syndromes”[65]. These paradigm shifts may be particularly
helpful for youth suicide prevention efforts, improving
early detection. More specifically, although nearly 90%
of youth who died by suicide were identified as having
a mental disorder in psychological autopsy, up to 40%
under age 15 did not meet diagnostic thresholds [2].
Further, many of the youth diagnosed with mental illness
after death, may have been previously undiagnosed and
untreated for mental illness.
In recent years, structural and functional magnetic
resonance imaging studies have illustrated normal and
abnormal brain development in youth. Puberty begins
around age 8 to 11 for girls and for boys, on average,
one year later [68]. During puberty, the brain is more
“plastic”, allowing youth to explore and master changing
environments requiring greater autonomy. Over time,
grey matter peaks and then declines while white matter
increases (myelination), reflecting the brain’s organizational
changes where the most frequently used connections are
strengthened and preserved. Disrupting these processes
can influence the onset of mental disorder. For example,
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SEX/GENDER DIFFERENCES IN TYPES OF
MENTAL DISORDERS AND SUICIDE
Prospective and retrospective studies confirm that
50%-70% of adults with a mental disorder had one in
their youth[81]. In particular, disruptive or “externalizing”
disorders: Attention Deficit Disorder with Hyperactivity
(ADHD), Oppositional Defiant Disorder (ODD) and
Conduct Disorder (CD), are more prevalent in boys than
girls, and internalizing disorders: Depression, Anxiety,
including Post-Traumatic Stress Disorder, more prevalent
in girls than boys[82,83]. ADHD declines with age, whereas
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Rhodes AE et al . Sex/gender and youth suicide
depression and substance use disorders increase [84].
Anxiety disorders tend to precede depression (with some
continuing to co-occur with depression)[75]. Externalizing
disorders (rather than internalizing ones) seem to precede
adult substance use disorders and there is continuity
between youth and adult substance use disorders [81].
Substance use disorders may be more prevalent in boys
than girls[82].
A puzzling question pertaining to sex/gender differences
in psychopathology is why do seemingly different psy­
chopathologies, internalizing and externalizing, co-occur?
Population-based research indicates that ODD is linked to
such co-occurrences, not CD or ADHD[85]. Further, the
ODD link seems to be explained by irritability and has been
posited as a mood disorder variant[85,86], newly captured in
DSM 5 as Disruptive Mood Dysregulation Disorder[87].
Still, the need to better characterize irritability and its
persistence over time is recognized given that irritability may
precede and/or be better explained by other disorders (i.e.,
personality and/or bipolar spectrum disorders often not
identified in population-based studies of youth[88,89] but may
vary in age of onset and by sex/gender)[90,91].
For example, there is some evidence that when
externalizing behaviours (especially those before age 13)
precede depression, youth are more likely to experience an
irritable depression at age 18[92]. Further, among depressed
youth, those most likely to be depressed and irritable (vs
depressed, not irritable) were boys (OR = 4.26). Notably,
depressed boys did not differ from depressed girls on
non-episodic irritability but rather, “a change in the
child’s usual liability to be precipitated into anger”[93]. In
contrast, when girls were depressed and irritable, they
exhibited more CD (but not ODD symptoms) than boys.
Most of the depressed youth (70%), stayed in the same
depression-irritability group into adulthood (ages 19 to
21)[93], implying that reactive (vs proactive) aggression
persisted among depressed and irritable boys (vs girls).
Aggression, (intent to hurt or harm another) is more
likely physical in boys and indirect (relational) in girls[94].
Instrumental or proactive aggression has been related to
psychopathy, whereas, reactive aggression is thought to
arise from difficulties regulating emotional responses to
threats[95].
As noted earlier, nearly all youth who died by suicide
were identified in studies as having a mental disorder. The
most common, strongest risk factors were prior mood,
substance-use and disruptive disorders. Combinations of
these disorders lead to higher risks. Given mental disorders,
particularly mood and substance use disorders, are more
common in suicides among older youth[96-98], disruptive
disorders would seem implicated in younger youth,
consistent with studies on youth suicide attempts[39,40,47].
Compared to girls, boys’ suicides more often include prior
disruptive and substance use disorders. In contrast, girls’
suicides are more likely to include prior mood or eating
disorders[2,97-100]. Schizophrenia, though rare, is also a strong
risk factor. Still, it may be more common in boys than girls,
due to earlier onset in boys[101,102].
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Few studies of youth suicide have employed dimensional
measures of psychiatric morbidity. In one, dimensional
measures of harm avoidance (correlated with anxiety
and mood disorders) and irritability (correlated with
substance abuse) and aggressive acts (correlated with CD)
distinguished youth who died by suicide from their peers[103].
Another study (all ages), found that measures of impulsivity
and aggression were associated with a younger age at suicide,
independent of mental disorders[104]. It is well established
that substance use disorders are associated with suicide in
older youth, particularly males, but less so in older adults[104].
However, there has been less study of the acute effects of
alcohol consumption on suicide among youth[105,106]. Alcohol
may proximally enable suicidal acts, by decreasing arousal
or fear and/or inhibitions to act (i.e., decrease anxiousness
but increase impulsivity). Studies examining alcohol
concentrations among those who died by suicide indicate
about one third were intoxicated at the time of their death.
In fact, alcohol (at any level) was higher among males than
females and younger persons[107,108].
SEX/GENDER DIFFERENCES IN
PERCEIVED THREATS AND LOSSES
Sex/gender differences in adverse early environments
not only shape early risks, but may be compounded
by social expectations or norms, arising in subsequent
developmental contexts, influencing not only how
youth perceive threats or losses, but how they adapt
to them. Gender has been described as a relational
concept, something that is performed, which may be
relatively stable in some contexts but not others [109].
While youth are not passive, their micro and macro level
social contexts may model and reinforce conformity
to expected “masculine” or “feminine” perceptions,
emotions and behaviours[110], via differential monitoring,
rewards/punishments[109,111]. The degree of monitoring
and rewards/punishments likely varies across cultures and
within social networks but may be differentially directed
to boys or girls and developmentally conditioned.
Conflicts arise when youth are unable to meet their own
or other’s sex/gender expectations, hopes or aspirations,
and specific developmental contexts may be particularly
adverse or threatening. Feelings of defeat/humiliation or
entrapment (i.e., inability to escape), with low levels of
social support may increase risk of a suicide attempt[112].
The transition to adulthood is accompanied by numerous
changes, challenging youth’s sense of self or identity.
Perceived pubertal timing (earlier in girls, later in boys)
has been found to prospectively predict youth suicide
attempts[37]. In addition to the biological and physical
changes of puberty, youth face varying sex/gender
expectations to master transitions to adulthood, including:
academic performance; entering the labour force; forming
new social networks/peers outside the family, including
romantic partner(s) and possibly, having children/parenting.
Younger youth may be influenced more by adults
(parents, teachers); whereas, older youth, by their peers[76].
125
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Rhodes AE et al . Sex/gender and youth suicide
Among youth who died by suicide, interpersonal stressors
have been associated with suicide and vary with age.
Before age 16, family conflicts were apparent; whereas,
in older youth, conflicts occurred within a romantic
relationship[98]. Media exposures (e.g., TV, movies, online/
social media) may act as a “super peer” by modeling
values and behaviours[113]. Indeed, there is concern about
how the growing use of less regulated, more interactive
media among youth contributes to suicidal behaviours[114].
Knowledge of and access to lethal methods is socially
scripted[109], and knowledge of a peer (but not necessarily
a friend) who died by suicide is prospectively associated
with a suicide attempt in youth[115].
Before we highlighted how early adverse environments,
in particular child maltreatment, may differ for boys and
girls, increasing their suicide risk. As youth age and their
social environments expand, they may face new, adverse
or threatening environments which vary by sex/gender
and developmental context. For example, peers may
discriminate against sexual minorities and/or promote
unrealistic expectations such as an idealized physical
appearance. Bullying involves an imbalance in power, is
intentional and repeated, occurring online and offline.
Both bullies and those who are bullied are more likely to
experience suicidal ideation and attempt suicide. Although
the association with being bullied (peer victimization) and
suicidal ideation does not seem to differ by sex/gender,
it is unclear whether is true for suicidal behaviour[116].
However, as mentioned, boys and girls differ in how
they express aggression, which is related to how they
bully[117,118]. Intimate partner violence contributes to suicide
attempts, an association most evident in girls[119]. Sexual
minority youth are known to be at a greater risk of suicide
attempts. Not only do they encounter bullying from their
peers, but they may also face rejection, maltreatment and
discrimination from family and others during a critical
time in their development[120-123].
It has been postulated for boys beginning to define
themselves as adult men. It may be especially difficult
to attain “masculine” norms of personal autonomy and
attainment. Such ideals may be discrepant with actual
achievements and/or broader socio-economic realities,
undermining the “human need to belong and form
lasting significant personal relationships”[124]. Men have
been found to have greater mental health risks than
women during acute economic downturns, (i.e., increased
unemployment). In particular, European men aged 15
to 24 were most affected by the 2008 global economic
recession, with an 11.7% increase in suicide rates[7].
Qualitative studies illustrate how micro environments
may reinforce masculine norms of personal autonomy
and attainment as youth age. Mac An Ghaill et al[125]
2012 described how British pre-adolescent boys were
confused and unhappy with treatment from teachers. For
example, teachers praised girls for being good pupils, and
physically separated boys from “their mates” encouraging
isolation and competition between them. Further, among
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their peers, boys learned not to speak of being scared
by “real things” to avoid exclusion[125]. In another study,
Irish men (aged 18 to 30 years) seen in hospital after
attempting suicide identified that their lower educations
limited their opportunities, including moving out of their
environments[126]. Given their backgrounds, they did not
recognize their experience as connected to mental illness,
nor did they see treatment as relevant. Some spoke of
being unable to “come out” as gay. (A problem inherent
in suicide risk determination in psychological autopsy
studies[127] but also in inferences about major causes of
mortality)[128]. Instead, men tried to mask their “pain”
through alcohol and/or drugs to project strength. When
their “pain” worsened, including sleeplessness, they did
not tell others as they feared being rejected by their peers
for being weak and burdening their partners, who might
leave them.
These experiences not only mirror “thwarted belon­
gingness and perceived burdensomeness”[129], but also
neuroimaging studies demonstrating pain networks are
activated when social exclusion is perceived[130]. Also,
according to this Interpersonal Theory[129], the acquired
ability for suicide comprises habituation to pain. Still,
most research on pain sensitivity has examined nonsuicidal self-injury rather than suicidal behaviours in
youth[112]. Denying or suppressing pain has been posited as
more common in male youth, of relevance to the gender
paradox[131].
SEX/GENDER DIFFERENCES IN
ADAPTATIONS TO PAIN
Fearful youth may avoid some contexts given heightened
sensitivity to non-rewarding cues. Self-disclosure may
be viewed as potentially harmful[110,132,133]. Further, if
youth are oppositional and/or aggressive, they may
be unwantedly or unexpectedly rejected by their peers.
Affiliation with more “deviant” peers may be rewarding,
provided such peers can be found and are more tolerant.
However, isolation may be reinforced, and the impact of
threats or loss, stronger[110]. Affiliating with delinquent or
substance abusing peers has been associated with a suicide
attempt among youth[134,135] and contributes to adjustment
difficulties among youth exposed to childhood sexual
abuse[136].
Substance use
Given “masculine” norms of personal autonomy, boys
may try managing pain through substance use. In some
contexts, including birth cohorts, alcohol use is more
socially acceptable and males provided more drinking
opportunities [137,138]. Further, given opportunities to
drink alcohol, youth with a history of childhood sexual
abuse are more likely to do so[138] and boys (but not
girls) with a history of sexual abuse tend to binge drink
more than their peers[139]. While alcohol may be used
to self-medicate[140], binge drinking is associated with
126
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Rhodes AE et al . Sex/gender and youth suicide
Table 1 Proposed sex/gender antecedents of youth suicide
Genetic vulnerabilities and sex/gender differences in early adverse environments affect neurodevelopment and sex/gender differences in:
Early internalizing and externalizing (co)morbidity where ODD ± anxiety symptoms or disorders precede:
Irritable depression with more reactive or “impulsive” aggression in boys
Irritable depression with more proactive or “planned” aggression in girls
Substance misuse
Mood and/or substance use disorders (not necessarily diagnosed or treated)
Sex/gender differences in perceived threats and losses
Sex/gender differences in adaptations to pain (e.g., disclosure, and to whom) and suicide attempt methods
ODD: Oppositional Defiant Disorder.
a temporary increase in depression which improves
after 2 to 4 wk abstinence. Thus, if drinking is stopped
or controlled, it may not be perceived as problematic.
However, if it continues, intake will likely increase
contributing to social isolation/exclusion, e.g., through
academic/work difficulties and/or aggressive acts[19,141,142].
Notably, an interpersonal loss, (e.g., a romantic breakup),
has been found to independently increase the risk of
suicide for boys (under age 20 years), but not girls,
possibly because girls had more confidants[143]. Further,
such interpersonal loss has been more strongly associated
with youth suicide in the presence of substance abuse
and the absence of conduct disorder (but not influenced
by depression)[144,145].
CONCLUSION
The age-dependent gender paradox observed in youth
may be explained by several factors that vary according
to genetic vulnerabilities and the contexts boys and girls
are born into and interact with as they age. In this final
section, we return to the premise, introduced earlier, that
given brain plasticity lessens in adulthood, interventions
that alter environment(s) and/or a youth’s abilities to
adapt to them, may have more enduring protective effects
(i.e., for those individuals and future generations) if first
implemented in youth. Integrating findings on sex/gender
differences in the continuum of suicidal behaviour with
genetic, neurodevelopment, psychiatric (co)morbidity
and social contexts that shape sex/gender perceived
threats and losses and adaptations to pain, we propose the
following antecedents to youth suicide (Table 1) which, if
acted on, may reduce suicide risk in boys and girls.
Help-seeking
Masculine norms of personal autonomy may also prevent
boys from seeking help. Youth help-seeking preferences
have been examined in relation to: the source of help
(i.e., informal: family and friends or formal: health
professionals), the type of problem and timing. Surveys
of high school students suggest that the developmental
trends differ in boys and girls. That is, over the course
of high school, girls increasingly identify friends and
professionals as likely sources for help with personalemotional problems, with less dependence on family.
Although boys also report seeking out family members
less, they do not compensate with friends or professional
help as much as girls[146]. Others have examined helpseeking attitudes in boys and girls. In a self-report
attitude survey (in six high schools) on managing
suicidal behaviour and depression, boys were more likely
to endorse items consistent with avoidant strategies
(including not telling others). In contrast, girls, scored
higher on approach strategies[147]. Further, while both
boys and girls tended to connect suicide with adverse life
experiences rather than mental disorder, this was truer
for boys than girls[148]. Such a stance may reinforce the
desire for self-management. In a study among university
students who screened positive for depression, alcohol
use or prior suicide attempt, the main reason for not
seeking professional help was their problems were
minor or transient, most apparent among heavy alcohol
users[140]. In sum, youths’ interactions with others in
specific contexts may not only contribute to perceived
threats and losses and pain and but also, how youth adapt
to these experiences.
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ACKNOWLEDGMENTS
We would like to thank Carolyn Zeigler MA MISt for
assisting with the literature review and Louisa Schilling
for assisting with the manuscript preparation.
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